Pre-screening form for Cognition Research of Cambridge (COGCAM)

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1.I consent to be contacted by Dr Chamberlain's Research Team at the University of Cambridge about studies that may be of interest to me. I understand that my information will be treated confidentially and will not be shared with anyone outside the research team.

Yes

No

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2.Name

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3.Gender

Male

Female

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4.Where do you live?

Cambridgeshire

Norfolk / Suffolk

Other (please specify)

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5.How would you prefer to be contacted?

Email

Telephone

Post

Please enter your email/telephone/address where you wish to be contacted

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6.Do you have any medical conditions?

Yes

No

If yes, please list them

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7.Are you taking any medications?

Yes

No

If yes, please list them

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8.Do you smoke?

Yes

No

If yes, how much per day roughly?

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9.Do you drink alcohol?

Yes

No

If yes, how many units of alcohol do you drink per week, on average? (e.g. a large glass of wine, or pint of beer, counts as two units. A single shot of spirit is one unit)

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10.Have you used any illicit substance(s), in the past six months? (e.g. cannabis, cocaine, ecstasy...)

Yes

No

Prefer Not To Say

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11.Have you ever had a major head injury that led to an inpatient hospital stay?

Yes

No

If yes, please provide further details

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12.Have you felt depressed and down, most of the day, nearly every day, for the past week?

Yes

No

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13.Have you ever been diagnosed with bipolar disorder, psychosis, or personality disorder?